Pennsylvania Department of Health
 SOUTH HILLS ENDOSCOPY CENTER
Patient Care Inspection Results

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SOUTH HILLS ENDOSCOPY CENTER
Inspection Results For:

There are  33 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
SOUTH HILLS ENDOSCOPY CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a State licensure survey conducted on May 21, 2024, at South Hills Endoscopy Center. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.











 Plan of Correction:


555.3 (b) LICENSURE Requirements:State only Deficiency.
Privileges granted shall reflect the results of peer review or utilization review programs, or both, specific to ambulatory surgery.
Observations:

Based upon a review of facility credential files (CF), and employee interview (EMP), it was determined that the facility failed to utilize the results of peer review or utilization for the re-appointment of nine of ten credential files reviewed (CF1, CF2, CF3, CF4, CF5, CF6, CF7, CF8, and CF9).


Findings include:


On May 21, 2024, a review of the Medical Staff Rules and Regulations (Last Reviewed and Adopted: January 18, 2024) revealed, "Requirements for Membership and Privileges- 2.(a) Privileges granted shall reflect the results of peer review or utilization review programs, or both, specific to ambulatory surgery."

On May 21, 2024, a review of CF1 revealed re-appointment to the medical staff on 01/19/2024. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF2 revealed re-appointment to the medical staff on 02/19/2023. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF3 revealed re-appointment to the medical staff on 01/19/2024. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF4 revealed re-appointment to the medical staff on 01/19/2024. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF5 revealed re-appointment to the medical staff on 01/19/2024. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF6 revealed re-appointment to the medical staff on 01/19/2024. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF7 revealed re-appointment to the medical staff on 02/01/2023. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF8 revealed re-appointment to the medical staff on 02/01/2023. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024, a review of CF9 revealed re-appointment to the medical staff on 02/01/2023. There was no evidence that either peer review or utilization review was utilized during the process of re-appointment.


On May 21, 2024 at 12:15 PM, EMP1 confirmed the above.










 Plan of Correction - To be completed: 05/29/2024

A peer review summary sheet was created by Beth and Becca.

Effective immediately, a peer review summary sheet will be part of the re-credentialing process. The peer review summary will include transfers, infection control and procedures completed in a credentialing time period.

The peer review policy 4.3, physician and nursing, was updated to state that peer review utilizing the peer review summary sheet will be given to medical staff, then governing body for review.
555.3 (d)(1-2) LICENSURE Requirements:State only Deficiency.
Granting of clinical privileges shall follow established policies and procedures in the bylaws or similar rules and regulations the procedures shall provide the following.
(1) Written record of the application, which includes the scope of privileges sought and granted. The delineation "clinical privileges"shall address the administration of anesthesia.
(2) A review, summarized on record with appropriate documentation of the qualifications of the applicant.

Observations:

Based on a review of facility documents, credential files (CF), and employee interview(EMP), it was determined that the facility failed to follow established policies when granting re-appointment to the medical staff for four of ten credential files reviewed (CF2, CF7, CF8, and CF9).


Findings include:


On May 21, 2024, a review of the Medical Staff Rules and Regulations (Last Reviewed and Adopted January 18, 2024) was completed and revealed, "Requirements for Membership: 2. c. (i-ii) Granting of clinical privileges shall follow established policies and procedures in the by-laws or similar rules and regulations. The procedures shall provide the following: i. A written record of the application, which includes the scope of privileges sought and granted. The delineation clinical privileges shall address the administration of anesthesia. ii. A review, summarized on record with appropriate documentation, of the qualifications of the applicant."

On May 21,2024, a review of CF2 revealed the delineation of privileges was signed on 01/09/2023. However, the review CF2 by the Medical Executive Committee did not occur until 01/10/2023.


On May 21,2024, a review of CF7 revealed the delineation of privileges was signed on 01/09/2023. However, the review CF7 by the Medical Executive Committee did not occur until 01/10/2023.


On May 21,2024, a review of CF8 revealed the delineation of privileges was signed on 01/09/2023. However, the review CF8 by the Medical Executive Committee did not occur until 01/10/2023.


On May 21,2024, a review of CF9 revealed the delineation of privileges was signed on 01/03/2023. However, the review CF9 by the Medical Executive Committee did not occur until 01/10/2023.

The above findings were confirmed by EMP1 on May 21, 2024 at 11:45 AM.





 Plan of Correction - To be completed: 05/29/2024

The director of nursing and administrator were educated during an in service to ensure the completion of credential files were reviewed prior to Governing Body approval. The medical director will approve delineation of privileges during or after the Medical Executive Committee meeting.

An audit will take place on each new and re-credentialed file for the next year or until 100% compliance is achieved.

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